Adverse Childhood Experiences Questionnaire

Adapted from BRFSS Screening Questionnaire (CDC)

To be completed by Clinician with Parent/Guardian or Child/Youth

Today’s Date:__________________________________

Child’s Name:__________________________________ Date of Birth:_________________________

Your Name:____________________________________ Relationship to Child:_______________

Stressful life events experienced by children and teens can have a profound affect on their physical
and mental health. This questionnaire can assist your healthcare provider in assessing these
stresses. Please read each statement below and indicate whether it applies to the you or your child/teen.

Item 1= Yes/0= No

A person in the household often or very often acted in a way that made the child/teen
afraid that they would be hurt (e.g., sworn at, insulted, put down, humiliated)

A person in the household often or very often hit, pushed, grabbed, or slapped the
child/teen so hard that they had marks or were injured

A person touched the child/teen’s private parts or asked them to touch their private
parts

Child/teen often or very often felt that people they lived with did not love them, look
out for each other, feel close to each other, or were a source of strength and support

Child/teen often or very often did not have enough to eat or clean clothes to wear, and
did not have someone to take care of and protect them

Child/teen’s parents or guardians were separated or divorced

Child/teen witnessed a person in the household being pushed, grabbed, hit, or

physically threatened

Someone the child/teen lived with had a problem with drinking or used street drugs

Someone the child/teen lived with was depressed, mentally ill or attempted suicide

Someone the child/teen lived with served time in prison

Total:
Sources:

Centers for Disease Control and Prevention (2016). Adverse Childhood Experiences (ACE). Retrieved from:
http://www.cdc.gov/violenceprevention/acestudy/

Centre for Youth Wellness, ACE-Q questionnaire, Section 1: https://centerforyouthwellness.org/cyw-

aceq/

Dong, M., Anda, R. F., Felitti, V. J., Dube, S. R., Williamson, D. F., Thompson, T. J., Loo, C. M., Giles, W. H.
(2004). The interrelatedness of multiple forms of childhood abuse, neglect, and household dysfunction.
Child Abuse and Neglect, 28, 771-784.

Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F. Spitz, A. M. Edwards, V., Koss, M. P. Marks, J. S.
(1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of
death in adults: The Adverse Childhood Experiences (ACE) study. American Journal of Preventative
Medicine, 14, 245-258.